physiotherapist don mills and steeles

By: Team Family Physio

The cervical spine is the region of the spine that we often refer to as the neck.  It spans the area from the head to slightly above the shoulder blades.  Changes in movement due to poor posture, muscle imbalances and past injuries often have a variety of presentations and can result in headaches, shoulder pain, mid back and altered sensation or pain in the arms.  This blog post will discuss a very common clinical presentation of poor movement and strength of the upper neck, a cervicogenic headache.

Anatomy of the upper cervical spine

The cervical spine is the upper region of the spine.  They are numbered from C1 (the top vertebra) to C7 (the bottom vertebra). The bony upper cervical spine consists of the upper 3 cervical vertebrae and the head.    This region is often described as the craniovertebral region.

The joint formed by the head on the C1 bone is the occipto-atlantal (OA) joint.  The joint between the C1 and C2 is the atlantoaxial (AA) joint.  Cervical discs do not appear in the upper cervical spine until the level of the C2/3 joint.  Numerous muscles attach in this area.  Some attach to one or 2 local regions of the spine whereas others have attachments into the shoulder blade, collar bone and even the lumbar and thoracic regions of the spine.  The local small upper muscles at the back of the craniovertebral region as a group are often referred to as the suboccipital muscles.

This region of the spine is  designed for movement and does not have as strong of a weight bearing capacity as the low back joints. The joints are commonly referred to as facet or zygoapohyseal (or “z” joints).  These joints differ in the upper and lower regions of the neck.  The facet joints of the OA and AA regions are oriented in a very flat plane (almost parallel to the ground when sitting or standing).

Movement of the craniovertebral region

Movement of the OA joint

The OA joint contributes to nodding movements (as if you are saying “yes”).  The joint surface resembles a ball sitting in a cup.

The AA joint

The AA joint when moving appropriately contributes primarily 45 degrees of head rotation to each side, allowing us to check our blind spot on either side from just this region.  The joint surfaces have resemble two tennis balls balanced on each other.  The rotational movements of the upper neck is a combination of twisting, compressing and side bending that easily occurs when the joint is flexible and muscles are not interfering with the movement.

The pattern of movement that the upper cervical spine performs causes a sideways bend in the opposite direction of a rotation movement.  For example, with a turn to the left it will cause a side bend to the right. If restriction of movement is present in this area the lower regions of the neck can make up for it with more muscle activation required and different stresses on the lower joints of the neck.

Posture and the craniovertebral region

An adult head weighs about 10 pounds and in a normal upright posture the weight of the head is balanced over the cervical spine and allows the shoulders to pull comfortably backwards.  Typical forward head posture results in an overuse of the suboccipital muscles making the chin poke forward in line with the chest.  With ongoing forward head posture the joints may lose the ability to move out of this posture. An increased load is now place on the muscles of the back of the neck to prevent the head from collapsing forward.

In a day to day context, consider standing and holding a 10 pound weight close to your chest compared to at arm’s reach in front of you.  The further forward the weight is the heavier it feels and the more the muscles have to do to continue to hold the position.  While this might seem to be an oversimplification, small differences in the forward position of the head are compounded for many hours over the course of our upright day and can produce similar overuse or pain patterns.

Headaches and the upper cervical spine

A common source of headache pain can be attributed to the muscles and joints of the upper cervical spine. Headaches from this area tend to be described as an aching pain. This pain is often localized on one side of the head but can spread to the other side.  There can also be a radiation of pain into the neck and shoulder areas.



What can cause a cervicogenic headache?

Headaches from this region can be caused by stiff joints, muscle overuse or conversely by joints with excessive amount of movement.  This can be due to current or past injuries of the area such as car accidents, facial injuries, or concussions.  They can also be secondary to compensations for injuries in other areas such as the lower neck, jaw, shoulders or low back.  Though seemingly unrelated, these areas share a similar innervation to the craniovertebral region and can cause a referral of pain or tension to these areas, a process known as segmental facilitation.

When acutely painful, aggravating movements of the upper cervical facet joints are often associated with looking up or a sidebending movement of the head in one direction and a rotating movement in the opposite direction recreate symptoms. However, in most cases pain is felt with sustained poor posture that cause overuse of the muscles and joints of the upper neck. These postures may be due to an inappropriate ergonomic setup or as a compensation for other painful areas such as the lower neck, back or shoulders.

What can ease a cervicogenic headache

Avoidance of the aggravating postures, heat or cold may assist in reducing pain. Positions that decompress the joint, such as looking down or away from the pain, generally relieve the perceived headache and pain.  If other regions are contributing to the pain reducing the strain on those areas can assist in reducing the pain from a headache area.

How are Cervicogenic headaches treated?

The first step in reducing head and neck pain is often to try and determine the factors that led to it.  These may have included poor form with working out, inefficient ergonomic setup and previous injuries to the shoulders and jaw.

If your pain is persisting and attempts to stretch out the area have not resolved your pain, the next step is often an assessment by a physiotherapist with experience in assessing and treating the neck.  A detailed assessment including history of past injuries, medication use and poor response to treatment can all give indications of underlying factors not allowing your headache to resolve.  In addition a detailed biomechanical assessment including joint hypermobility testing, patterns of active and passive movement and strength tests are often included.

Stiff craniovertebral region

Headaches from stiff joints do not always resolve with general stretching programs until the joint movement improves with targeted manual therapy techniques.  These techniques should address not just the local factors causing the headaches but the other areas that are causing stress to the area. This may include exercises for the shoulder or jaw.  A joint that has been stretched needs to have the support of appropriate conditioned muscles otherwise symptoms will persist.

Mobile craniovertebral region

When the source of the cervicogenic headache is excessive amounts of movement, generalized techniques such as traction and muscle stretching tend to not help resolve the problems.  Stretches may give moments of relief as the overused muscles get a break, however the support that these muscles produce result in a return of symptoms shortly after the stretch is stopped.  Commonly the headache symptom can feel worse shortly after completing the stretch.  Treatment for this type of headache may include manual therapy techniques, however they need to specifically target the stiffer surrounding regions such as the mid cervical spine and shoulders without straining the pain generating areas.  With the upper and mid cervical spine being so close in proximity, the treatment of these types often utilizes post graduate skills to ensure that symptoms resolve as stiff surrounding regions become more mobile.  Exercises that improve the endurance of the small cervical stabilizing musculature are also key to resolving symptoms, not just managing them.

Not Sure Where to start?

You’re not alone. There are a number of risk factors that can cause symptoms to persist with generalized treatment approaches.  Our physiotherapists and massage therapists have the experience and training to evaluate and diagnose your current status and the tools to get you started and progressing towards better health.  Contact us to get started on your goals!



Edmondston et al “Influence of cranio-cervical posture on three-dimensional motion of the cervical spine” Manual Therapy (2005)

Jull, G.  “Characterization of the cervicogenic headache” Physical Therapy Review (1998)

Travell and Simmons Myofascial Pain and Dysfunction The Trigger Point Manual Wolters Kluer 1998

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